Healthcare Provider Details

I. General information

NPI: 1184587685
Provider Name (Legal Business Name): JESSICA MARIE LEWIS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2025
Last Update Date: 12/03/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1108 ROSS CLARK CIR
DOTHAN AL
36301-3022
US

IV. Provider business mailing address

1201 TRAVIS RD
DOTHAN AL
36301-4721
US

V. Phone/Fax

Practice location:
  • Phone: 334-793-8111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number1-193665
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: